Protocol for a mixed-method analysis of implementation of case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs

Abstract

IntroductionCase management (CM) in a primary care setting is a promising approach to integrating and improving healthcare services and outcomes for patients with chronic conditions and complex care needs who frequently use healthcare services. Despite evidence supporting CM and interest in implementing it in Canada, little is known about how to do this. This research aims to identify the barriers and facilitators to the implementation of a CM intervention in different primary care contexts (objective 1) and to explain the influence of the clinical context on the degree of implementation (objective 2) and on the outcomes of the intervention (objective 3).Methods and analysisA multiple-case embedded mixed-methods study will be conducted on CM implemented in ten primary care clinics across five Canadian provinces. Each clinic will represent a subunit of analysis, detailed through a case history. Cases will be compared and contrasted using multiple analytical approaches. Qualitative data (objectives 1 and 2) from individual semistructured interviews (n=130), focus group discussions (n=20) and participant observation of each clinic (36 hours) will be compared and integrated with quantitative (objective 3) clinical data on services use (n=300) and patient questionnaires (n=300). An evaluation of intervention fidelity will be integrated into the data analysis.Ethics and disseminationThis project received approval from the CIUSSS de l'Estrie – CHUS Research Ethic Board (project number MP-31-2019-2830). Results will provide the opportunity to refine the CM intervention and to facilitate effective evaluation, replication and scale-up. This research provides knowledge on how to resp ond to the needs of individuals with chronic conditions and complex care needs in a cost-effective way that improves patient-reported outcomes and healthcare use, while ensuring care team well-being. Dissemination of results is planned and executed based on the needs of various stakeholders involved in the research.

Case Study With a Participatory Approach: Rethinking Pragmatics of Stakeholder Engagement for Implementation Research

“…Finally, a "middle ground" approach 20 may be to adopt a pragmatic posture (as proposed by Merriam), where researchers use a case study with a participatory approach to conduct an implementation analysis of a health care innovation while consulting community or organizational stakeholders in certain phases of the research. Adopting this epistemological posture, we will present the example of the PriCARE program 5,6 in the next section.…”

“…Although stakeholders may contribute to this step, in PriCARE, it was the academic research team who decided to use a combination of the Consolidated Framework for Implementation Research 21 and the Rainbow Model of Integrated Care Framework, 25 combining the concepts of primary care and integrated care. 6 The academic research team took responsibility for explaining theoretical frameworks to stakeholders through brief, informal online meetings, to ensure a common comprehension and facilitate participation and engagement of all stakeholders throughout the research process.…”

“…In this multijurisdictional Canadian study, the research team and stakeholders aimed to evaluate the implementation of a case management intervention in 10 primary care clinics, for frequent users of health care services with chronic diseases and complex care needs. 5,6 It is important to first distinguish the case study with a participatory approach from the participatory case study before proceeding with the example of the PriCARE program.…”

Reconciling Validity and Challenges of Patient Comfort and Understanding: Guidelines to Patient-Oriented Questionnaires

“…The PriCARE research program [15,16] Network programmatic grants. The program's overarching goals are to 1) generate ndings on the implementation of case management (CM) in primary care for individuals with chronic conditions and complex healthcare needs who frequently use healthcare services, and 2) implement an evidence-based intervention to improve care experience and outcomes and to guide policy decision-making.…”

“…One or two primary care clinics were recruited in each province to implement and evaluate the CM intervention among frequent users of healthcare services with chronic diseases and complex care needs. The intervention is detailed elsewhere [15]. To meet the inclusion criteria for the program, participants must be: over 18 years of age, living with at least one chronic condition (including mental health), have complex health care needs, heavy use of health care services according to professional judgment, and could bene t from the intervention.…”